Functional electrical
stimulation (FES)
to aid walking after stroke
Updated: July 2013
Review Date: July 2014
Different Strokes
0845 130 7172 or 01908 317618
[email protected]
Who is this booklet for?
This booklet may be of interest if your stroke has caused drop foot (dropped
foot or foot drop). This is one of the most common mobility problems
following stroke. Functional Electrical Stimulation (FES) is clinically
proven to improve walking speed, and reduce the effort of walking.
Do you have questions?
Would you like to speak to someone with personal
experience of stroke?
Call our Helpline:
0845 130 7172
or 01908 317618
9:00 to 5:00
Monday to Friday
Or write to:
9 Canon Harnett Court
Wolverton Mill
Milton Keynes
MK12 5NF
Email: [email protected]
Website: www.differentstrokes.co.uk
Facebook: www.facebook.com/groups/differentstrokesuk
Twitter: @diffstrokes
2
Contents
Chapter
1
2
3
4
5
6
7
8
9
10
Page
Clinical problem
4
Treatment options
5
Functional electrical
stimulation
6-7
What does it involve?
8-9
What are the benefits?
10-11
Are there any risks or side
effects?
12
How do I get FES?
13
FES clinical guidelines
14
Feedback from members
15
List of FES suppliers
16
3
1
Clinical problem
Drop foot is one of the most common mobility problems following stroke.

Drop foot (also dropped foot or foot drop) is the inability to lift the
foot and toes properly when walking. It can lead to trips and falls, and a
loss of confidence when walking.

Functional Electrical Stimulation (FES) uses small electrical impulses
to assist the muscles to lift the foot. It is clinically proven to improve
walking speed, and reduce the effort of walking.
Drop Foot occurs when the muscles are not strong enough
to lift the foot and toes. It can also occur if the foot lift is
hampered by tight or overactive calf muscles due to
spasticity. Weakness relating to drop foot can also cause the
person to hit the ground on the outside of the foot, which
may increase the risk of ankle injuries. In all cases drop foot can lead to trips
and falls, and slow inefficient walking.
The individual often loses confidence, especially when
walking outside. Drop foot can therefore have a negative
impact on everyday activities such as household tasks, social
activities, and hobbies.
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2
Treatment options
The initial treatment for drop foot is usually physiotherapy. This includes
exercises and gait training.
Although an AFO can assist with the drop foot, it can
make standing up from sitting, and using stairs, harder
because the shin can be prevented from moving over the
foot. As an AFO can restrict voluntary movement, muscles may become
weaker through not using them. It is possible that this may also prevent
recovery of voluntary movement.
Other treatment options include medication (Baclofen or Botulinum Toxin
commonly known as Botox) and, less commonly, surgery.
5
3
Functional electrical
stimulation
Functional Electrical Stimulation (FES)
FES uses small electrical currents to stimulate the nerves that connect to the
paralysed muscles. This causes the muscles to contract. FES can be used
to stimulate nerves in the arms, legs, trunk and buttocks in order to achieve
a range of functional movements.
FES for drop foot correction
FES is particularly beneficial for drop foot. The peroneal
nerve is easy to stimulate as it lies just under the skin and
the lower leg muscles it supplies generally respond well
enough to lift the foot at the ankle.
How does it work?
The FES current is generated by a small battery-powered electronic device.
There are two ways of delivering the current to the nerve:
6
Surface (external) FES
The most common way is to use electrodes placed on the skin over the
nerve. It is important that the electrodes are accurately placed each time
FES is used if the correct movement is to be produced. This requires either
that the user accurately positions the electrodes for themselves, or they are
aided by attaching a cuff below their knee that positions the electrodes on
the leg. The user will experience a “pins and needles” sensation when the
current is applied, which most people quickly become used to.
Implanted FES
This involves surgery in which the electrodes are placed
directly onto the nerves and controlled by a small implant
placed under the skin. The FES device activates the implant
through a wireless antenna worn on the outside of the body.
Implanted devices remove the need to position electrodes on the skin each
day. They also significantly reduce or eliminate the sensation associated with
external stimulation. External FES is used to test that walking is improved
with FES before receiving the implant.
7
Triggering
The muscles need to be stimulated to lift the foot at the right time during
walking. So, the stimulation needs to be triggered when weight is taken off
the foot until just after the weight is returned to the foot. This provides foot
clearance when swinging the leg and ankle stability when the foot lands.
Two trigger systems are currently used. One uses a pressure sensitive foot
switch that is placed in the user’s shoe, usually under the heel. The foot
switch and FES device can be connected either with a wire or using a
wireless link. The second system for triggering is from the movement of the
user’s leg detected using a tilt sensor. The sensor is contained within the
FES device mounted on a leg cuff.
The majority of FES users choose to use the device every day. However
some people choose to use it for specific activities such as walking outside
the house or at times when they need extra help with their walking. All FES
devices can be easily turned on and off by the user. FES should be turned
off when driving.
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4
What does it involve?
In order to gain the most benefit from FES, individuals must be able to walk
a few steps. This can be with assistance and/or using a walking aid. FES
may be used by people with less ability during physiotherapy sessions when
learning to walk after their stroke.
Before you can be provided with an FES system you will
require a careful assessment by an FES specialist. They
will ask you about your general health, medical history and
what you are hoping to achieve with FES. They will then
consider whether it is safe for you to use FES. Precautions include
pregnancy, active cancers, poorly controlled epilepsy, and other implants
such as cardiac pacemakers.
The clinician will attempt to find the position of the
electrodes on your leg that produces the best lift of your foot
with the minimum intensity of stimulation.
When an effective foot lift is achieved in sitting, the clinician
will then make sure the device reliably triggers whilst you are walking and
that the foot clears the ground with every step. The clinician will then
observe the way you walk with FES. They may need to make adjustments to
the electrode positioning, stimulus intensity, or timing of the stimulation.
9
In some cases, they may need to stimulate an additional set of muscles,
such as those that control the hip, knee or arm to further help you with your
walking. It is usually quick and easy to establish whether FES will be helpful.
Once satisfied with the outcome, the clinician will train you in the use and
maintenance of your FES device.
Once you are provided with an FES device, it is
common to record outcome measures such as
walking speed, the effort of walking or questionnaire
based measures at each clinic session.
As your walking progresses with FES, this may enable you to engage in
more activities. As a result, some further adjustments may be required to the
FES device. For this reason it is important to attend regular follow up
sessions. Follow up is normally 3 to 6 times in the first year, and then every
6 or 12 months thereafter.
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5
What are the benefits?
Studies have demonstrated that FES for drop foot can lead
to the following benefits:

More natural walking pattern

Improved walking speed

Ability to walk longer distances

Improved confidence

Increased independence in activities of daily living

Improved safety with a reduced incidence of falls

Walking becomes less tiring

Reduced spasticity

Walking becomes easier on uneven surfaces

A training effect – most stroke survivors after a period of using FES
show an improved walking speed even when the FES is switched off.
This effect might not occur with every user or be permanent.
Many FES users report that these benefits enable them to enjoy a better
quality of life. The evidence from these studies was reviewed by the National
Institute for Health and Clinical Excellence (NICE). Their published guidance
states that drop foot FES is a safe and effective treatment. The “National
Clinical Guideline for Stroke” published by the Royal College of Physicians
also recommends FES for drop foot. A similar document has also been
published by Health Improvement Scotland.
11
6
Are there any risks or
side effects?
When using surface electrodes, the
stimulation will be felt as ‘pins and needles’ and in the
majority of cases is well tolerated. The use of surface
electrodes can, in a small number of cases, lead to skin
irritation. These cases are usually treated by changing the type of
electrodes, the stimulation settings or by switching to the use of an
implantable system.
Patients who undertake surgery for implantable FES devices have the same
small but recognised risks associated with any surgery and general
anaesthetic..
12
7
How do I get FES?
Your GP can refer you to a number of NHS
funded FES Services. However, in some regions, an FES
service may not be offered or automatically funded for all FES
devices available on the market. Your GP or treatment
specialist can make an individual funding request for any FES
device on your behalf — although there is no guarantee that
your application will be accepted.
The full range of FES devices can also be funded privately and are available
through a number of physiotherapy clinics and other healthcare providers.
13
8
FES clinical guidelines
National Institute for Health and Clinical Excellence.
Interventional procedures overview 278: Functional
electrical stimulation for drop foot of central neurological
origin. 2009. ISBN 1846298474
http://publications.nice.org.uk/functional-electrical-stimulation-for-drop-foot-of
-central-neurological-origin-ipg278
National Institute for Health and Care Excellence. Clinical Guideline 162:
Stroke rehabilitation - Long-term rehabilitation after stroke. 2013. ISBN
9781473101579. http://guidance.nice.org.uk/CG162/NICEGuidance/pdf/
English
Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke,
4th edition London: Royal College of Physicians 2012. ISBN
9781860164927 http://www.rcplondon.ac.uk/resources/stroke-guidelines
Health Improvement Scotland. Evidence note 46. The use of functional
electrical stimulation (FES) in adults with dropped foot. 2012.
http://www.healthcareimprovementscotland.org/programmes/
clinical__cost_effectiveness/shtg_-_evidence_notes/evidence_note_46.aspx
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9
Feedback from members
“I've been using FES for my foot drop for about 3 1/2 years. I personally
think that it is amazing and couldn’t get around without it! I have just got
back from a 3 week trip to Asia, which wouldn’t have been possible without
my FES.”
“As I'm regaining strength in my left leg it has definitely helped me control
the spasms more… It is really trial and error coupled with a lot of patience. I
would highly recommend this to anyone with drop foot.”
“It’s great and gives my foot more freedom to move than when I used my
AFO (rigid support). It does take a bit of patience getting in the right position
but its worth it. ...”
“It has taken me several months to get the hang of positioning the
electrodes. But it is helping and gives a good lift to my foot. The wires can be
a bit trying and working out how to wear the box of tricks took a while. I wear
mine on a lanyard round my neck. It's easily disguised with a scarf “.
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10
List of FES suppliers
The content of this booklet is based on a document authored by Mr Jon
Graham (Clinical Director, PhysioFunction Ltd.), and commissioned for
writing by the manufacturers of the FES devices. The content has been
checked and reviewed by leading FES clinicians and Different Strokes.
Bioness
Odstock Medical
Limited
0800 411 8100
01722 439 540
[email protected]
enquiries@odstockmedical.
com
www.bioness.com/
United_Kingdom.php
www.odstockmedical.com/
Ottobock
Trulife UK
01784 744900
0800 581 596
neurostimulation_uk@
ottobock.com
[email protected]
www.dropfoot.co.uk
www.trulife.com
16
A Bioness L300 user, wearing the optional thigh stimulation cuff.
Users of the ActiGait (implantable) and MyGait (external) systems by
Ottobock.
17
Odstock Drop Foot Stimulator (ODFS®)
I am no longer dependent on other people - I can just go.
Trulife WalkAide
18